J Extra Corpor Technol 2023 , 55 , 157 – 158 Ó The Author ( s ), published by EDP Sciences , 2023 https :// doi . org / 10.1051 / ject / 2023043
Available online at : ject . edpsciences . org
EDITORIAL
Extracorporeal cardiopulmonary resuscitation : lifesaving for the right patient , at the right time and in the right place
Prolonged extracorporeal cardiopulmonary support is a medical technology that exemplifies one of the most substantial medical advances in life-saving modalities for patients with cardiorespiratory failure refractory to conventional treatment . This technology is referred to as extracorporeal membrane oxygenation ( ECMO ) or extracorporeal life support ( ECLS ). Driven by the success of ECMO in treating acute respiratory patients with H1N1 influenza during the global pandemic in 2009 , the use of ECLS has skyrocketed worldwide for adult patients with both respiratory failure and cardiac failure [ 1 ]. However , the fastest-growing application of ECLS in the last several years is extracorporeal cardiopulmonary resuscitation ( ECPR ) as an additional link in the chain of survival in patients with refractory cardiac arrest [ 2 ]. It is a complementary intervention when return of spontaneous circulation is not obtained within a reasonable timeframe despite high-quality conventional cardiopulmonary resuscitation ( cCPR ). ECPR restores and maintains circulation , while buying time for clinicians to identify and potentially reverse the etiology of the event , for example by coronary angiography and subsequent intervention .
Safety and effectiveness of ECPR remain unclear as most data are derived from case series , single-center studies or inconclusive results from randomized clinical trials . Furthermore , the most recent European Resuscitation Council guidelines characterized the evidence supporting ECPR as being very low [ 3 ]. Although the first documentation of successful ECPR originated from 1966 , mortality following ECPR in adults remains high , over 70 % [ 4 , 5 ]. Undoubtedly , this poor prognosis is related to manifest end-organ ischemia despite ECPR .
Recent reports demonstrate survival to hospital discharge with favorable neurologic outcome in a subset of patients [ 6 , 7 ]. In these reports , factors to take into account when assessing suitability of ECPR were described . For example , a Japanese study examining data from 120 patients suggests that the first detected heart rhythm is an important determinant of neurologically intact survival , favoring ventricular fibrillation and tachycardia over pulseless electric activity and asystole [ 8 ]. Unfortunately , due to the lack of large randomized trials , as well as profound heterogeneity in patient and study characteristics , a robust algorithm to help timely identification of suitable candidates for ECPR is not yet available .
In this issue of the JECT , Gutiérrez-Soriano et al . [ 9 ] and Michalakes et al . [ 10 ] share their experiences with positive and negative outcomes following ECPR for in-hospital and out of hospital cardiac arrest cases . Both case reports highlight key selection criteria and features of developing an ECPR program , emphasizing that improving the outcome of ECPR is multifactorial , with the most identifiable factors being the development of ECLS teams , the optimization of advanced cardiovascular life support and ECPR workflow , and the experience of healthcare providers . Furthermore , to improve ECPR outcome , timing is a crucial aspect i . e ., limiting the no-flow time ( without CPR ) and low-flow time ( with cCPR ) [ 11 ]. Only when circulation is restored , further oxygen debt accumulation is prevented , while sufficient flow is necessary to enable repayment of oxygen debt [ 12 ]. In other words , the key factor to ECPR success is minimization of the time to oxygen debt resolution .
Along with the expected metabolic and coagulopathic derangements , ECLS treatment is inherently associated with a high rate of complications such as bleeding , neurologic issues , and infection [ 2 ]. Clinicians should also take reperfusion injury into account , particularly cerebral , that may need mitigation [ 2 ]. Moreover , successful initiation and weaning from ECLS does not equal survival to hospital discharge , as patients remain susceptible to complications related to the underlying pathology or the received treatment .
Finally , ECPR is a highly complex salvage therapy for when initial cCPR fails in selected cardiac arrest patients . Indeed , ECPR is a multidisciplinary intervention that requires significant resources and training , which are not universally available . While clinicians are challenged to assess the recovery potential of a particular patient i . e ., the presumed reversibility of circulatory failure , prolonged decision time will lower the chances of survival drastically . Future studies should aim at unraveling the efficacy of ECPR and factors associated with acceptable neurocognitive outcomes .
Patrick W . Weerwind , PhD , CCP-Retired Associate Editor
Nousjka P . A . Vranken , MD , PhD Invited Editor
Dept . of Cardiology , Maastricht University Medical Center ,
Maastricht , the Netherlands
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